TO BE COMPLETED BY SUPERVISOR. APPROVED DISAPPROVED RETURNED FOR CORRECTION
TO BE COMPLETED BY SUPERVISOR. The approving supervisor must complete the agreement status information section. If a telework agreement is disapproved, the reason(s) for disapproval must be identified and the employee informed of the disapproval in accordance with DR 0000-000-000, Telework Program.
TO BE COMPLETED BY SUPERVISOR. Supervisor’s Full Legal Name: ___________________________________________________________ Employers Name: _____________________________________________________________________ Employer’s Address: ___________________________________________________________________ Street __________________________________________________________________ City State Zip Employers Phone #: __________________ Employers Email address: __________________________ Title at Place of Employment: ___________________________________________________________ Address of the location where the supervision shall take place: __________________________________ _____________________________________________________________________________________ Street _____________________________________________________________________________________ City State Zip Is the location of where the supervision to take place confidential? Yes No All candidates must have a W-2 work relationship with employer. Do you have this type of relationship? (Independent contractor relationship not permitted) Yes No I hold a current, valid license in NH as: (Check all that apply) [ ] Pastoral Psychotherapist [ ] Clinical Social Worker [ ] Clinical Mental Health Counselor [ ] Marriage and Family Therapist License number(s): _____________________________________________________________________ Have you been licensed in NH for more than two years? Yes No Mhp 302.01 (c)(9), requires supervisors to have successfully completed one of the following. Indicate “Yes” or “No” to questions 1 – 3 and attach documentation that shows proof of completion. Graduate level course in clinical supervision? Yes No Clinical supervision approved by one of the following? Yes No Association for Clinical Pastoral Education; National Association of Social Workers; American Mental Health Counselors Association; or American Association for Marriage and Family Therapy Twelve continuing education units (CEUs) in clinical supervision through participation in a seminar or workshop approved by a Category A sponsor listed in Mhp 402.02 (a)(1). Yes No Are you an employee of your supervisee’s clinical site? Yes No If you answered “no” to this question attach a written statement which addresses the following: Your relationship to the candidate’s employer/clinical site. Acknowledging that you will provide supervision at the candidate’s place of employment/clinical site where the applicant delivers services, at a mutually convenient and ethically appropriate site, ...
TO BE COMPLETED BY SUPERVISOR. APPROVED
TO BE COMPLETED BY SUPERVISOR. Decision: The employment contract shall be amended to add hours of work. The workload shall be reduced to match the number of hours of work stated in the employment contract. The number of hours of work stated in the employment contract is appropriate for the required workload. Comments: Signature: Date:
